While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

The client's comfort level is increased when the nurse breaks eye contact to type notes into the record.

Completing the electronic record during an interview is a legal obligation of the examining nurse.

The nurse has limited ability to observe nonverbal communication while entering the assessment electronically.

The interview process is enhanced with electronic documentation and allows the client to speak at a normal pace.

Answer and Explanation

The Correct Answer is C

Choice A reason: This is an incorrect statement as it implies that breaking eye contact is beneficial for the client. In fact, breaking eye contact may reduce the client's trust and rapport with the nurse. The nurse should maintain eye contact as much as possible and use verbal and nonverbal cues to show active listening.

Choice B reason: This is an incorrect statement as it implies that electronic documentation is mandatory for all interviews. In fact, electronic documentation is not a legal obligation, but a preferred method of recording the assessment data. The nurse should follow the facility's policy and procedure for electronic documentation and ensure the accuracy, completeness, and confidentiality of the record.

Choice C reason: This is the correct statement as it acknowledges the challenge of electronic documentation during an interview. The nurse may miss some important nonverbal cues from the client, such as facial expressions, gestures, or posture, while typing on the computer. The nurse should balance the time spent on the computer and the time spent on the client and use open-ended questions and reflective statements to elicit more information.

Choice D reason: This is an incorrect statement as it implies that electronic documentation is beneficial for the interview process. In fact, electronic documentation may interfere with the flow and quality of the interview. The client may feel rushed or ignored by the nurse's attention to the computer. The nurse should pace the interview according to the client's needs and preferences and use electronic documentation as a tool, not a barrier.

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Correct Answer is B

Explanation

Choice A reason: Requesting a family member to remain with the client is not the best intervention to implement first. It may provide some emotional support, but it does not address the communication barrier. The family member may not be able to translate accurately or objectively, and may have their own biases or emotions.

Choice B reason: Obtaining a staff member who is a bilingual interpreter is the best intervention to implement first. It ensures effective communication and understanding between the nurse and the client. It also respects the client's cultural and linguistic preferences and needs.

Choice C reason: Using drawings that are universal for all cultures is not the most effective intervention to implement first. It may be helpful for some simple concepts, but it may not convey the full meaning or context of the assessment. It may also be misinterpreted or misunderstood by the client.

Choice D reason: Asking for the support of one of the client's friends is not the most appropriate intervention to implement first. It may violate the client's privacy and confidentiality, and may not ensure accurate or unbiased translation. The friend may not be familiar with the medical terminology or the client's condition.

A. Print electronic medical record (EMR) from backup server. B. Notify information services department of the situation. C. Identify information as late entry in the record. D. Wait for notification that the system has been rebooted.

Correct Answer is B

Explanation

Choice A reason: Printing electronic medical record (EMR) from backup server is not the best action to take first. It may not be possible or feasible to access the backup server if the system is down. It may also delay the communication and delivery of the prescriptions to the lab.

Choice B reason: Notifying information services department of the situation is the best action to take first. It alerts the experts who can troubleshoot and fix the problem as soon as possible. It also allows the nurse to obtain guidance on how to proceed with the documentation and prescriptions.

Choice C reason: Identifying information as late entry in the record is a relevant action to take, but not the first one. It ensures the accuracy and completeness of the EMR, but it does not address the immediate issue of the system failure. The nurse may not be able to enter the information until the system is restored.

Choice D reason: Waiting for notification that the system has been rebooted is not a proactive action to take first. It may waste valuable time and compromise the client's care. The nurse should not assume that the system will be rebooted automatically or quickly.

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While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

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